HEAD AND NECK AND NEURO HEAD AND NECK BLOCK 2 EXAM SIMULTANEOUSLY 1 - WRITTEN EXAM 18 Questions 4.90% of grade

2 - PRACTICAL EXAM 15 Questions Gross Anatomy 2.72% of grade

1) Prosections – already in lab; some correspond to photos; some structures not labeled 2) X-rays, Angiograms

NO SKULL SESSIONS: no questions on skulls

ATLAS HOLDING UP WORLD ADVICE ON HOW TO TAKE THE HEAD AND NECK EXAM

DRAW: 1. CRANIAL NERVE FUNCTIONAL COMPONENTS CHART 3. SVE MUSCLES - 'incantation' 4. BRANCHIAL ARCHES, POUCHES 5. GVE PARASYMPATHETICS - HITCHHIKING PATHWAYS - BRANCHES IX (VIDEO REVIEW) [6. BRANCHES OF MAXILLARY ARTERY] REVIEW

1. LARYNX 2. NECK - Compartments, Carotid Artery 3. PHARYNX - TONSILS, POPCORN 4. ORAL CAVITY LARYNX REVIEW: CARTILAGES

ARYTENOID - 2 pyramidal Sup. Horn shaped cartilages above lamina of cricoid

Arytenoid

Laryngeal lamina prominence = Adam's apple Cricoid Inf. Horn

THYROID CARTILAGE CRICOID = signet ring - shield shaped - complete ring of cartilage - has Sup. and Inf. Horns - narrow Arch ant., broad Lamina - Laryngeal prominence post. LARYNX REVIEW: SYNOVIAL JOINTS

THYROID and CRICOID ARYTENOID and CRICOID

SLIDING

SYNOVIAL JOINT ROTATION BETWEEN ARYTENOID AND CRICOID HINGE JOINT

JOINTS PERMIT JOINTS PERMIT TILTING OF ROTATION AND THYROID-CRICOID SLIDING SOUND PRODUCTION: CONUS ELASTICUS top view VOCAL INTERNAL LIGAMENTS ELASTIC CONUS MEMBRANE ELASTICUS ATTACHED TO CRIOCID; UPPER FREE EDGES = VOCAL LIGAMENTS

VOCAL LIGAMENTS EXTEND FROM ARYTENOID TO THYROID, ACROSS TWO JOINTS

RIMA GLOTTIDIS = opening CHANGE PITCH BY TILTING AT HINGE JOINT – Thyroid cartilage tilts down; cricoid tilts up Tilting - STRETCHES THYROID ARYTENOID vocal ligaments

HINGE JOINT HINGE JOINT CRICOID RELAX vocal ligament STRETCH vocal ligament DECREASE PITCH - INCREASE PITCH - THYROARYTENOID CRICOTHYROID MUSCLES OF LARYNX

Tilting - STRETCHES vocal ligaments

HINGE JOINT

CRICOTHYROID M. - STRETCH vocal ligament Tenses INCREASE PITCH - Vocal Ligament CRICOTHYROID Increasing Pitch CRICOTHYROID M. MUSCLES OF LARYNX NOT SEE THYROID

HINGE THYROARYTENOID JOINT MUSCLES - adjacent to CRICOID vocal ligament - Relaxes RELAX vocal ligament Vocal Ligaments DECREASE PITCH - Decreases pitch THYROARYTENOID OPEN AND CLOSE RIMA GLOTTIDIS BY ROTATING/SLIDING ARYTENOIDS - Rotate laterally opens; Rotate medially or slide closes

OPEN CLOSE CLOSE ROTATE ROTATE SLIDE LATERALLY MEDIALLY

POSTERIOR LATERAL ARYT ENOIDEUS CRICO- CRICO- REST ARYTENOID ARYTENOID POSITION MUSCLES OF LARYNX

5) ARYTENOID (Transverse and oblique arytenoid) - Adduct vocal folds 4) LATERAL CRICO- ARYTENOID - Adduct vocal folds

3) POSTERIOR CRICO- ARYTENOID – Abducts vocal fold

Arytenoids Adduct closes rima glottidis Can rotate/slide Abduct opens rima glottidis ARYTENOIDEUS

POSTERIOR LATERAL CRICO- CRICO- ARYTENOID ARYTENOID IV. TERMS ASSOCIATED WITH LARYNX

Bisect Larynx to see interior structures NOSE TERMS ASSOCIATED WITH LARYNX

epiglottis VESTIBULE - inlet above false vocal folds

VESTIBULAR (FALSE VOCAL) FOLDS - overlie vestibular ligaments

VENTRICLE - area between true and false vocal folds; lateral extension is Laryngeal Sinus

VOCAL (TRUE VOCAL) FOLDS - overlie vocal ligaments

Clinical - Anaphylactic shock - mucosa tightly attached at vocal folds; swelling of vestibular folds blocks airway CORONAL SECTION VESTIBULE - inlet Quadrangular above false vocal membrane folds

VESTIBULAR (FALSE VOCAL) FOLDS - Ventricle overlie vestibular ligaments (lower edge of Quadrangular membrane) Conus VOCAL (TRUE elasticus VOCAL) FOLDS - overlie vocal ligaments (upper edge of Conus elasticus) NERVES OF LARYNX – Branches of Vagus

SUP. LARYNG. N. 1) Superior Laryngeal N. a) Internal Laryngeal N. GVA Sensory to Larynx Above (true vocal folds) b) External Laryngeal N. SVE Motor to Cricothyroid

Int. Laryng. N. 2) Recurrent Laryngeal n. - GVA Sensory to Larynx True Vocal Folds Ext. Laryng. N. - SVE motor to all other

RECURRENT Muscles of Larynx LARYNG. N. Clinical - damage to Recurrent Laryngeal nerve in Thyroid surgery NERVES X X OF SUPERIOR SUPERIOR LARYNX – LARYNGEAL LARYNGEAL Branches of NERVE NERVE - pierces Vagus thyrohyoid membrane

RIGHT LEFT RECURRENT RECURRENT LARYNGEAL LARYNGEAL NERVE - passes NERVE - passes under under Subclavian Arch of Artery Aorta FASCIA OF NECK

Deep Cervical fascia - one layer surrounds neck, other layers form tubes (names poorly chosen) 4. Carotid sheath 2. Prevertebral Layer 3. Pre-tracheal layer

1. Investing layer N FASCIA OF NECK O S E Pretracheal Prevertebral Layer- surrounds layer vert. column & muscles back of Carotid neck, prevertebral, lateral Sheath vertebral and suboccipital m.

Pretracheal Layer- surrounds trachea, esophag. & thyroid continues to mediastinum

Carotid Sheath- surrounds common & int carotid, int jugular and X (not: Symp. Chain)

Retropharyngeal Space- between PreTrach & Pre Vert layers -infection from head Prevertebral (tonsillitis) can spread to layer mediastinum Pretracheal 272 layer

Carotid Sheath

Prevertebral layer

Retropharyngeal Carotid sheath Space is anterior to vertebrae A. MUSCLES OF NECK - NOT ATTACHED TO HYOID - move head & neck MOST IMPORTANT LANDMARK IN NECK 1. STERNO- CLEIDOMASTOID

0 - Two heads 1) manubrium of sternum 2) clavicle- medial 1/3 I - mastoid process of PULL MASTOID TOWARD STERNUM temporal bone Act - bilateral - flex head; unilateral rotate head, face to directed opposite side TORTICOLLIS – Inn - CN XI Accessory n. Contracture of Sternocleidomastoid TRIANGLES OF NECK

Sternocleidomastoid muscle - divides neck into anterior & posterior triangles

Posterior Anterior triangle - triangle - Preveretebral Pretracheal layer; Brachial layer; Contents plexus, cervical of Lateral plexus (Phrenic compartment: nerve); Carotid sheath Subclavian artery MUSCLES OF NECK - NOT ATTACHED TO HYOID

2. SCALENUS ANTERIOR AND SCALENUS MEDIUS O - vertebrae- trans processes upper cervical FLEXION I - rib 1 A - flex neck & elevate rib 1 Inn - ventral rami of cervical spinal nerves SECOND MOST IMPORTANT LANDMARKS IN NECK Anterior triangle - Pretracheal layer; Contents of Lateral Posterior triangle - compartment: Preveretebral layer; Carotid sheath Brachial plexus, cervical plexus (Phrenic nerve); Subclavian artery Post side Ant side

SUP. TEMPORAL POST. AURICULAR MAXILLARY

OCCIPITAL POSTERIOR BRANCHES FACIAL LINGUAL ANTERIOR BRANCHES

SUP. THYROID 1. COMMON CAROTID 2. INTERNAL CAROTID 3. ASCENDING PHARYNGEAL 4. OCCIPITAL * 5. SUPERFICIAL TEMPORAL POSTERIOR 6. MIDDLE CEREBRAL BRANCHES 7. ANTERIOR CEREBRAL 8. MIDDLE MENINGEAL 9. MAXILLARY 10. FACIAL 11. LINGUAL 12. EXTERNAL CAROTID 13. SUPERIOR THYROID

*- OPHTHALMIC ARTERY ARISING FROM CAROTID SIPHON

ANTERIOR BRANCHES POSTERIOR ANTERIOR BRANCHES BRANCHES PHARYNX - is continuous with esophagus, opens to larynx trachea

PHARYNX

HYOID BONE

LARYNX ESOPHAGUS PHARYNX

All Pharynx is GVA Nasal In 3 Cranial Nerves Cavity GSA NASOPHARYNX - VII soft palate Oral OROPHARYNX - IX Cavity epiglottis GSA LARYNGOPHARYNX - X PHARYNX Tell Constrictors Apart by level

SUPERIOR CONSTRICTOR Sup. O - Pterygomandibular Raphe Const. (Conn. Tiss. Lig. from Med. Pterygoid plate to Mandible - CONTINUOUS ANT. WITH Mid. BUCCINATOR) Const.

MIDDLE CONSTRICTOR Inf. O - HYOID Const. INFERIOR CONSTRICTOR O - THYROID & CRICOID Cartilage Structures Through Gaps In Constrictors PHARYNX

1) Between Sup. Constrictor and Skull Levator Veli Palatini M. Auditory Tube Sup. 2) Between Sup. and Mid. Constrictor Const. Glossopharyngeal N. (IX) Stylopharyngeus M. Mid. Const. 3) Between Mid. and Inf. Constrictor Superior Laryngeal A. Internal Laryngeal N. Inf. Const.

1037 276

Carotid sheath is anterior to vertebrae CONTENTS OF PHARYNX

in Nasopharynx Soft - Pharyngeal Tonsil (Adenoids) Palate - opening of Auditory Tube in Oropharynx - Palatine Tonsils (Tonsillitis) posterior to Palatoglossal Arch PALATINE TONSILS - LOCATION

PALATO- GLOSSAL ARCH

PALATO- PHARYNGEAL ARCH

PALATINE TONSIL

AAH! PALATINE TONSILS - Tonsillectomy - incise mucosa

TONSILLAR BR. OF FACIAL A.

IX

Tonsillar ‘Bed’ - Formed by 1) Superior Constrictor of Clinical - pharynx and 1) Damage IX 2) Styloglossus 2) Bleeding PHARYNX - INTERNAL STRUCTURES

CLINICAL VIGNETTE

PIRIFORM RECESS: lateral to inlet of larynx

Inlet of 2 Larynx

A child complains that he has popcorn stuck in his throat. Examination shows that it is lodged in the laryngopharynx, lateral to the inlet of the larynx. The popcorn is in the ______. PHARYNX - INTERNAL STRUCTURES

VALLECULAE - in Oropharynx

1 ORAL CAVITY - TONGUE

FORAMEN A. SUPERFICIAL STRUCTURES CECUM 1. SULCUS TERMINALIS - V- SHAPE GROOVE DIVIDES TONGUE INTO: ANT. 2/3- ORAL PART - GSA; POST 1/3 - PHARYNGEAL PART - GVA 2. FORAMEN CAECUM - PIT IN MIDDLE OF SULCUS TERMINALIS- SITE OF INVAGINATION OF THYROID GLAND SULCUS TERMINALIS CLINICAL QUESTION: MASS IN POSTERIOR TONGUE; CHECK IF IT IS THYROID TISSUE BEFORE SURGICAL EXCISION FOLDS, LANDMARKS BENEATH TONGUE

4. FIMBRIATED FOLDS (PLICA 3. LINGUAL FIMBRIATA) ( L. FRENULUM (L. FRINGE) - LATERAL BRIDLE) TO LINGUAL MIDLINE FOLD FRENULUM, FROM FLOOR LOCATION OF OF MOUTH LINGUAL VEINS

SUBLINGUAL 5. SUBLINGUAL PAPILLA- FOLDS (PLICA SWELLING AT SUBLINGUALIS) BASE OF OVERLIE & HAVE FRENULUM; OPENINGS FOR OPENINGS SUBLINGUAL SUBMANDIB. SALIV GLANDS SALIV. GLANDS MUSCLES OF TONGUE - all innervated by XII

A) GENIOGLOSSUS 1. EXTRINSIC MUSCLES - O - GENIAL TUBERCLE OF MANDIBLE I - TONGUE TO ITS DORSAL SURFACE ATTACH TONGUE TO A - PROTRUDE BONES

NOSE STYLOID C) STYLOGLOSSUS - PROCESS O-STYLOID PROCESS OF TEMP. BONE I - LAT. SIDE OF TONGUE A - DRAWS TONGUE SUPERIORLY & POSTERIORLY

B) HYOGLOSSUS - O - GREATER & LESSER HORNS OF HYOID BONE I - LAT. SIDE OF TONGUE MANDIBLE A - DEPRESS HYOID

GENIO- GENIO- GLOSSUS GLOSSUS INTACT LESION

XII - LESION - PROTRUDED TONGUE DEVIATES TOWARD SIDE OF LESION - due to unopposed action of the Genioglossus muscle. VEINS OF NECK

Post. Sup. Temp. Auricular 1. Superficial Temporal & Maxillary vv. form Max Retromandibular V. (RM) PD Facial 2. Retromand. V. Divides Ant. RM (AD) and Post. (PD) divisions AD 3. Ant. Division joins Facial V. Common to form Common Facial V. -> facial Int. jugular V. 4. Post. Division joins Post. Auricular V. to form External Jugular V-> Subclavian V. Ant jug 5. Ant. Jugular from veins below mandible -> Ext. Jugular External above clavicle Jugular VEINS OF NECK

Pattern of Venous Drainage

Good luck! 231

RETROPHARYNGEAL SPACE - posterior to Constrictors; anterior to Prevertebral muscles RETROPHARYNGEAL ABSCESS

Infection in retropharyngeal space can spread unimpeded to mediastinum